Healthcare Provider Details

I. General information

NPI: 1073235701
Provider Name (Legal Business Name): BALDWIN HARBOR PODIATRY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/19/2022
Last Update Date: 09/19/2022
Certification Date: 09/19/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

830 ATLANTIC AVE STE A
BALDWIN NY
11510-4098
US

IV. Provider business mailing address

830 ATLANTIC AVE STE A
BALDWIN NY
11510-4098
US

V. Phone/Fax

Practice location:
  • Phone: 516-623-4580
  • Fax: 516-623-4588
Mailing address:
  • Phone: 516-623-4580
  • Fax: 516-623-4588

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number
License Number State

VIII. Authorized Official

Name: KIM BERLIN
Title or Position: OWNER
Credential: DPM
Phone: 516-623-4580